THE ELDERLY or IMPAIRED DRIVER

WARNINGIn  a Cochrane review  of driving assessments for maintaining mobility and safety 

in demented drivers

The  authors concluded that the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents

ELDERLY DRIVER FACTS

1. # of elderly drivers is rapidly increasing and they are driving further:By 2020 there may be 38 million older(>70) licensed drivers on the road. By 2030 almost ¼ drivers on highway will be > or =65

2. In a survey of 2,422 adults 50 and older, 86 percent reported that driving was their usual mode of transportation. Within this group, driving was the usual method of transportation for

85 percent of participants 75 to79,78 percent of participants 80 to 84,60 percent of participant’s 85 and older.

3. Driving cessation is inevitable for many and can be associated withnegative outcomes:

Social isolationD d t f h ti itiDecreased out-of-home activitiesIncrease in depressive sx

4. Many older drivers self-regulate their driving behavior.a y o de d e s se egu ate t e d g be a omany avoid night-time driving, avoid left hand turns, decrease mileage; however, not true for all and MVA/mile driven increases starting at age 65

4. Crash rate for older drivers is in part related to physical &/or mental changes associated with aging &/or disease: elder crashes tend tobe related to inattention or slowed speed of visual processing:

often multiple vehicle events at intersections with left hand turns

5. Physicians can influence their patients’ decisions to modify or stop & fdriving & can also help their patients maintain safe driving skills.

6. Driving abilities share many attributes that are necessary for successful ambulation, such as adequate visual, cognitive, andsuccessful ambulation, such as adequate visual, cognitive, andmotor function. In fact, a history of falls has been associated with an increased risk of motor vehicle crash.

Many pts will stop when we tell them; we can keep them on road longer by managing their diseases such as arthritis cataracts orlonger by managing their diseases such as arthritis, cataracts, or discontinuing sedating medications.

W d t b f t t d i i l f t d i i h bWe need to be aware of state driving laws, refer to driving rehab specialists, recommend driving restrictions, and refer to State authorities when appropriate

Assessing Patients for Driving SafetyHistory: Questions for Caregivers

h h d h l hHas the patient had any motor vehicle crashes?

Has the patient had any "near misses"?

Has the patient had any tickets?Has the patient had any tickets?

Has the patient been pulled over by police?

Have you noticed a change in the patient's driving behaviors fromHave you noticed a change in the patient s driving behaviors frombaseline? Since the last examination?

Has the patient had difficulty staying in a lane?

Does the patient have difficulty following the rules of the road?

Do other drivers honk at the patient?

A th t h th hi l ?Are there scratches on the vehicle?

Has the patient gotten lost in familiar areas?

Is the patient vigilant in scanning for vehicles/pedestrians?Is the patient vigilant in scanning for vehicles/pedestrians?

http://www.ama-assn.org/ama/pub/physician-reso rces/p blic health/promoting healthresources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.page

A condition in which a person who suffers from a disability seems unaware of the

i t f hi h di bilitexistence of his or her disability

Physical Examination: Assessment for Comorbid Conditions That Can Further Reduce CapacityReduce Capacity

Visual: cataracts, diabetic retinopathy, macular degeneration, glaucoma

Cognitive: sleep apnea, multiple sclerosis, Parkinson disease, psychiatric disease, di b tdiabetes

Motor: degenerative joint disease, muscle weakness, neuropathy

Medication review: assessment for sedating agents

AntihistaminesAntipsychoticsAntipsychoticsTricyclic antidepressantsBowel / bladder antispasmodicsBenzodiazepinesMuscle relaxantsBarbiturates

Functional Assessment: Assessment of Instrumental Activities of Daily LivingFood preparation, finances, telephone, medications, shopping, housekeeping,laundry

Inability to do IADL can be a red flag that driving is impaired

1. Screen for red flags: medical illnesses, medications that may impair driving

2. Ask about new onset impaired driving behaviors

3. Ask driving-related functional skills in pts that are at increased risk

4. Treat any underlying causes of functional decline

5. Refer appropriate (if need eval &/or adaptive training) pts to driver rehab pp p ( p g) pspecialist

6. Counsel pts: safe driving behavior, restrictions, cessation, &/or alternative transportation optionstransportation options

7. F/U to see if made changes; eval for depression and social isolation

IS THE PATIENT AT INCREASED RISK FOR UNSAFE DRIVING?

1. Observe pt at office visit? Impaired personal care? Impaired ambulation or getting into or out of chair?difficulty with visual tasks? Impaired attention, memory, language , expression, or comprehension

2 Be alert to red flags: any condition medication or sx that can affect2. Be alert to red flags: any condition, medication , or sx that can affect driving-see next slide

3. If pt or family asks if they are safe to drive, identify reason for the concern

4. Ask how much pt drives, what problems they have with driving, are you a safe driver?, have you ever gotten lost while driving, any tickets, any near crashes?crashes?

RED FLAGS

Acute events: mi, cva, arrhythmia, syncope, seizure, surgery, delirium, new sedating meds

Pt f il b ’Pt or family member’s concern

Interaction of chronic medical conditions on their function: vision,c-v, neurologic, dm, arthritisg , ,

Intermittent/unpredictable events: syncope, angina,tia, hypoglycemia, sleep attacks

medications

ASSESSING FUNCTIONAL ABILITY

VISION, COGNITION, MOTOR/SOMATOSENSORY FUNCTION

VISIONACUITY—various states require >20/40 or <20/70

SNELLEN CHART for distance ROSENBAUM CHART for near visionSNELLEN CHART for distance, ROSENBAUM CHART for near visionVISUAL FIELDS—confrontation

COGNITION:h l kimemory, short, long term, working memory

visual perception processing, search, visuospatial skillsselective and divided attnexecutive skills: sequencing, planning, judgment, decision makingexecutive skills: sequencing, planning, judgment, decision makinglanguagevigilance

if cognitively impaired, do not rely on copilot: if can’t drive without copilot, h ld t d ishould not drive

ADR SADReSASSESSMENT OF DRIVING-RELATED SKILLS

Vi l Fi ld M t  St th

• Seven Components:• Seven Components:

Visual Fields Visual AcuityR id P  W lk

Motor Strength Trail‐Making Test, Part B Rapid Pace Walk

Range of Motion

Part B Clock Drawing TestTest

ADReS

Component:

Visual Fields

How Tested:

Confrontation

Result Signaling Need for Intervention:

Any field cutAny field cut

ADReS

Component:Visual AcuityVisual Acuity

How Tested:

Snellen or Rosenbaum chart

Result Signaling Need for Intervention:Result Signaling Need for Intervention:Varies by state; most commonly, best corrected vision of 20/40 requiredcorrected vision of 20/40 required

ADReS

Component:

Rapid Pace Walk

How Tested:Mark 10 foot distance; Time patient walking 10 ft., turning, walking backg g g

Result Signaling Need for Intervention:

Time > 9 secondsTime > 9 seconds

ADReS

Component:Range of MotionRange of Motion

How Tested:N k t ti fi l h ld &Neck rotation, finger curl, shoulder &elbow flexion, ankle plantar- &dorsiflexion Simulate driving positiondorsiflexion ---Simulate driving position

Result Signaling Need for Intervention:A li i ll i ifi t d fi itAny clinically significant deficit

ADReSComponent:

Motor StrengthMotor Strength

How Tested:

Shoulder, wrist, hand grip, hip, ankle

Result Signaling Need for Intervention:Result Signaling Need for Intervention:<4/5 in either upper extremity or right lower extremitylower extremity

ADReS

Component:

T il M ki T t P t BTrail-Making Test, Part B

How Tested:

Standard form

Result Signaling Need for Intervention:

> 180 seconds> 180 seconds

TRAILMAKING TEST PART B is a good test for general cognitive function—poor performance correlates with poor drivingpoor performance correlates with poor driving

Assesses working memory, visual processing , visuospatial skills, selective & divided attention, psychomotor coordination

ADReS

Component:

Clock Drawing Test

How Tested:How Tested:

Standard form

Result Signaling Need for Intervention:

Any abnormal elementAny abnormal element

DRIVER REHAB SPECIALISTplan, develop, coordinate, implements driving services for disabled pts

They evaluate pt, often have computer programs that predict safety, can do on road functional assessment, recommend arrange adaptive equipment

Generally the cost is out of pocket—we do have this available at the VAGenerally the cost is out of pocket we do have this available at the VA through OT

LOCATE outside driver rehab specialist: www.driver-ed.org or d dwww.aded.net

Counseling pt who is no longer safe to drive

Physicians have an ethical responsibility to protect the patient’s safety through eval of their driving behavior, and when all options h b h t d t d i i ti Ad i f MD ihave been exhausted to rec driving cessation—Advice from MD is the most frequently cited reason that a pt stops driving

Explain why and discuss pts thoughts and feelings but don’t getExplain why, and discuss pts thoughts and feelings—but don t get into dispute or long explanation—document in chart

• Need to assess impairments that might adversely affect drivingNeed to assess impairments that might adversely affect driving abilities:

• Must be able to identify and document: physical and mental impairments that clearly relate to ability to drivep y y

• Driver must pose a clear risk to public safety• Before reporting: need candid discussion, advise of options,

negotiate workable plan --? Need rehab or OT, or only drive during daytime,etc

Di t t ti i tDiscuss state reporting requirements Protect confidentiality: only minimum amount of info reported and

appropriate security measures used in handling the information

Explore transportation alternatives and give pt resources to explore alternatives—social worker can help

Encourage family/caregiver assistance: good websites:Encourage family/caregiver assistance: good websites:

www. nfcacares.org

http://www.alz.org/safetycenter/we_can_help_safety_driving.asp

If family member not there, communicate to family member if pt does not have capacityhave capacity

HIPPA has a regulation that allows for reporting information that includes pt’s protected health info when it is in the public interest.

Not all states protect health providers when they report. However, some states require you to report.

AMA polic states that it is desirable and ethical to notif DMVAMA policy: states that it is desirable and ethical to notify DMV

If pt continues to drive and you know it:ask pt why and if they understand the law and legal, financial p y y gconsequences; if cognitively impaired, notify family—can notify DMV

MEDICAL CONDITIONS THAT CAN AFFECT DRIVING—SEEMEDICAL CONDITIONS THAT CAN AFFECT DRIVING—SEEAMA Physician's Guide to Assessing and Counseling Older Drivers

http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.shtml

Specifically chapter 9—goes into detail about most medical conditions

Some common salient points3 ft l t i t ti VT3 mo after last seizure, symptomatic VT4 wks after median sternotomy or 8 wks after heart transplantAfter AICD implantation: (from AHA)for primary prevention: recovery from operation(at least 1 wk)p y p y p ( )for secondary prevention : 6 months

See also JAMA VOL 303 #16, 4/28/10 CLINICIAN’S CORNERGOOD ARTICLE + MANY RESOURCES LISTEDGOOD ARTICLE + MANY RESOURCES LISTED

P ti P t d t E l ti d tPractice Parameter update: Evaluation and management of driving risk in dementia

Neurology 2010 74: 1316-1324

Table 1: Summary of recent studies on dementia and driving performance.

Author, Year Study design Study populationAssessment

methodKey findings

Alzheimers Disease (AD)

Ott BR, 2008 [47]Prospective cohort

52 patients with AD (CDR = 0.5) versus 32 patients with AD (CDR = 1)

ORT

Median time to driving restriction due to failure on road test, at-fault motor vehicle accident or dementia progression was 605 days for CDR = 0.5 and 324 days for CDR = 1

Duchek JM, 2003 [55]Prospective cohort

21 patients with AD (CDR 0.5),

29 with AD (CDR 1.0) and 58 elderly controls

ORT

At baseline, 41% of subjects with CDR = 1 versus 14% with CDR = 0.5 versus 3% with CDR = 0 were judged as unsafe drivers. Mean time of follow-up until persons were judged as unsafe was <3 months for CDR = 1, 10 months for CDR = 0.5 and 14 ymonths for CDR = 0

Dawson JD, 2009 [46] Cross sectional

40 subjects with AD (mean MMSE 26.5 ± 2.5) versus 115 elderly controls

ORTSubjects with AD committed 80% more safety errors than controls. Lane observance errors were more common in drivers with AD

Frittelli C, 2009 [42] Cross sectional

20 patients with AD (mean MMSE

22 ± 4) versus 19 age-matched controls

Driving simulatorAD patients showed a higher number of lane violations and a longer mean latency in visual reaction time compared to controls

Whelihan WM, 2005 [80]

Cross sectional23 patients with AD (CDR = 0.5) versus 23 age-matched controls

ORT Patients yielded significantly higher values on a weighted assessment score, meaning poorer driving performance

Frontotemporal Dementia (FTD)

De Simone V, 2007 [31] Cross sectional

15 subjects with FTD versus 15 controls matched for age, gender and education

Driving simulatorFTD patients committed significantly more safety errors, the most important being speed violations, off-road accidents, collisions and ignored stop signs

CDR = Clinical dementia rating; ORT = On-the-road Test; MMSE = Mini-Mental State Examination.

1 Generally mmse by itself does not predict driving safety—MMSE<24 is1. Generally mmse by itself does not predict driving safety—MMSE<24 is possibly useful

2. 76% of pts with mild dementia still pass ORDT(on the road driving test)

3. CDR is useful for for identifying pts at increased risk for unsafe driving; however a substantial # of drivers with CDR 0.5-1 still pass ORDT

4. Pt’s rating of their ability to drive is not useful; caregiver’s assessment is probably useful

For pts with dementia, consider the following characteristics useful for identifying pts at increased risk for unsafe drivingidentifying pts at increased risk for unsafe driving

CDR scale LEVEL A

C i ’ ti f t’ bilit i l f LEVEL BCaregiver’s rating of pt’s ability as marginal or unsafe LEVEL B

LEVEL C:hx of traffic citationshx of crashesreduced driving mileageself reported situational avoidanceMMSE<24MMSE<24Aggressive or impulsive personality characteristics

For demented pts, consider the following characteristics NOT useful for identifying unsafe driving

LEVEL A A t lf ti f f d i i bilitLEVEL A: A pts self rating of safe driving ability

LEVEL C: Lack of situational avoidance

LEVEL U: insufficient evidence to support or refute the benefit of n/p testing, after controlling for the prescence and severity of dementia

Ability of Neuropsychological Tests and Test Batteries to Predict Performance on Road Testsa

Carr, D. B. et al. JAMA 2010;303:1632-1641.

Copyright restrictions may apply.

SAMPLE ALGORITHM FOR EVALUATING DRIVING COMPETENCESAMPLE ALGORITHM FOR EVALUATING DRIVING COMPETENCE AND RISK MANGEMENT IN PTS WITH DEMENTIA

Figure 114">

Iverson, D. J. et al. Neurology 2010;74:1316-1324

Approach to Evaluating Older Adults With Cognitive Impairment or Dementia

Copyright restrictions may apply.

Carr, D. B. et al. JAMA 2010;303:1632-1641.

AM I A SAFE DRIVER?

I t l t hil d i iI get lost while drivingMy friends or family are worried about my drivingOther cars appear from nowhereI have trouble finding and reading signs in time to respond to themg g g pOther drivers drive too fastOther drivers honk at meDriving stresses me outAfter driving I feel tiredAfter driving, I feel tiredI feel sleepy while drivingI’ve had more near misses latelyBusy intersects bother meLeft hand turns make me nervousThe glare from oncoming headlights bother meMedication makes me dizzy or drowsyI have trouble turning steering wheel or pushing down the foot pedalI have trouble turning steering wheel or pushing down the foot pedalI have trouble looking over my shoulder while I back up

I have been stopped by police for me drivingPeople will no longer ride with meI h t bl b kiI have trouble backing upI’ ve had at fault accidents in the past yrI am too cautious while drivingI sometimes forget to use my mirrors or signalsg y gI sometimes forget to check for oncoming trafficI have more trouble parking

If + response to any, your safety may be at risk

STEPS FAMILY MEMBERS CAN TAKE TO ENSURE DEMENTED PTS DON’TSTEPS FAMILY MEMBERS CAN TAKE TO ENSURE DEMENTED PTS DON’T DRIVE

1. Ask md to rx driving cessation orally and in writingg y g2. Ask md to use medical conditions other than dementia as the reason: slow

reflexes, impaired vision,3. Use contract4 Hide file down or replace car keys with ones that won’t start car4. Hide, file down or replace car keys with ones that won t start car5. Remove car or don’t repair6. Disable vehicle7. Ask family lawyer to discuss with pt, family ramifications of continued driving

Consider using a handout like the Hartford’s “We Need to Talk” which can be

d t th f ll i b itaccessed at the following website; www.thehartford.com/talkwitholderdrivers/brochure/brochure.htm or writing the Hartford and requesting brochures at;Thea o d a d eques g b oc u es a ; eHartfordWe Need to Talk200 Executive BoulevardSouthington, CT 06489

If concerned about your relative’s driving

Expert Recommendations of Professional Societies and Consensus Meetings

REFERENCES UP TO DATE JAMA 2010;303(16):1632‐1641 PHYSICIAN’S GUIDE TO Assessing and Counseling Older Drivers,2010, AMA Swiss Medical Weekly 2011;140:w13136y ; 4 3 3 ACP PIER Cochrane Database Syst Rev  2009 Jan 21; (1) CD006222 JAMA  2011; 305 (10) 1018‐1026 Circulation 3/6/2007 1170‐1176Circulation 3/6/2007 1170 1176 Neurology 2010;74:1316–1324

More information for patients and caregivers: see APPENDIX B of AMA guide More information for patients and caregivers: see APPENDIX B of AMA guide